Motion made, and Question proposed,
That a further sum, not exceeding £4,290,850,000, be granted to Her Majesty out of the Consolidated Fund to defray the charges which will come in course of payment during the year ending on 31st March 1987 for expenditure by the Department of Health and Social Security on supplementary pensions and allowances.—[Mr. Major.]
§ Mrs. Renee Short (Wolverhampton, North-East)
I am grateful to the Liaison Committee for giving us some time this afternoon to debate this subject on an Estimates day. There is another debate to follow, so we shall have an opportunity to debate this matter fully.
As the House knows, we had only a few days' warning of the date of this debate, and I want to thank Her Majesty's Stationery Office and the printers for publishing our annual public expenditure report, which contains a section on this issue, in record time. I understand that that is available in the Vote Office now.
Under the supplementary benefit regulations the Department of Health and Social Security may pay benefit to elderly people living in residential care and nursing homes run by the private or voluntary sectors to meet the costs of their board and lodging. The cost of those payments has risen from £6 million in 1978 to an estimated £280 million in 1985. That is a considerable increase over seven years.
The size and speed of that increase in public expenditure is such that the Select Committee on Social Services thought it important to bring the matter urgently to the attention of the House. In the context of the total social security budget, £280 million is small—it accounts for less than 1 per cent. of all social security spending—but it is the equivalent of 10 per cent. of current spending on personal social services. Therefore, we are glad to have the opportunity to raise this matter in the House.
The Committee's concern is not that £280 million is an unreasonable amount to spend on supporting elderly people in need of residential care and without the means of paying for it themselves—for that reason I shall not be moving a reduction in the Vote — but that expenditure in this area has been quite out of the Department's control. That is the main burden of our criticism. The vast growth in spending is not the result of a well thought out policy decision and careful consultation; it has happened by accident and is the result of bureaucratic mismanagement.
I should have thought that, in spite of the fact that general managers have departed from the Elephant and Castle, there were enough people managing the various budgets of the Department to have kept an eye on this matter. However, it seems that they were not able to do so.
319 Before 1983 limits on the amount of supplementary benefit available for board and lodgings payment were determined locally and local DHSS offices had discretion to pay the full amount of a board and lodging charge, provided that it was not "reasonable" to expect the claimant to move to cheaper accommodation. "Reasonable" is the term used by the Department.
In November 1983, in the face of escalating costs, a new system was introduced. Locally determined maximum limits were set at a level reflecting the highest reasonable charge for suitable accommodation in the area. What was paid depended upon what private accommodation was available in the area. Therefore, there was a change in the direction of administration.
The introduction of maximum limits did nothing to control expenditure, which surged from £39 million in 1982 to £105 million in 1983 and to £190 million in 1984. Therefore, there were distinct and large increases. In 1985 expenditure had gone up to £280 million. Much of the increase was due to increased demand, but the average weekly cost per resident also jumped from less than £50 in 1982 to over £76 in 1983. Only a small part of the increase can be put down to inflation. Many homes simply increased their prices when they realised that the Department would pay the increased costs. It was a good jamboree for them. As the Committee reported, it is remarkable that the Department did not foresee that effect. It is surprising that a Government so committed to the operation of market forces did not realise that if one tells sellers that one is willing to pay more, prices will rise accordingly. That is what has happened.
§ Mr. Nicholas Winterton (Macclesfield)
To balance the argument that the hon. Lady is putting forward, I hope that she will agree that it is important to show the House that the figures the DHSS said it was prepared to meet were based on figures which were already in existence. I agree that they were at the higher rather than the lower level, but it is important to show that, in putting forward the recommendation, the DHSS based it on figures of cost already in existence. Perhaps some homes thought that if others were receiving higher amounts they should, too. However, the recommendation was based upon a realistic figure of what was already being charged at the better end of the market.
§ Mrs. Short
Yes. However, the effect of what was likely to happen was not monitored, and we are faced with this massive escalation in cost. It is considerable. I gave the total figures earlier.
In September 1984 the Department changed course again. Local limits were frozen and a review of residential care policy was announced. In April 1985, locally determined limits were abandoned in favour of national limits. Expenditure appears to have gone on rising to an estimated £280 million in 1985 and there is no evidence that it will be any less this year.
The number of residents in private and voluntary care supported by the supplementary benefit system increased from 7,000 in 1978 to 42,500 in 1984. That is a sixfold increase. In 1979, 14 per cent. of residents in private and voluntary homes for the elderly were supported by supplementary benefit. In 1984 the proportion of those supported had risen to 35 per cent., but the average weekly payment per resident had grown from £15.70 in 1978 to no less than £88 in 1984. That is a considerable increase.
320 The Committee tried to find out from the Department what had been achieved by that increase in cost: whether there had been a commensurate increase in the quality of the care provided. It was unable to tell us. The Committee also asked about the effect of introducing national limits: whether lower limits had reduced standards or whether any homes had been squeezed out of business. Again, the DHSS was able to tell us very little. It became clear, too, that the Department has not yet established how board and lodging payments will fit into the new structure of social security set out in the current Social Security Bill. The Minister told us in Committee that the present regime would "broadly continue". The Committee concluded:It seems extraordinary that the DHSS should not have worked out how this increasingly important area of social security spending is going to fit into the scheme of things in only two years' time.It is clear that more monitoring, more control and a better system of gathering information about the effects of the payments is needed.
Concern has been expressed about standards of care in private homes, especially the implications for residential care in the Department of Employment's recent White Paper "Building Businesses … not Barriers" which mooted some deregulation in that area. It is vital that standards of care are not sacrificed in the pursuit of profit. In fact, we want standards of care not only to be maintained but to be improved as increased payments are made. Ministers assured the Committee that there were no plans to remove controls, and the Minister for Social Security told us:The Government is firmly determined to ensure the proper control of standards in this area.It seems as if there has been a lack of communication between Government Departments, and that has resulted in the runaway increase in the total cost and the amounts paid.
There is a strong argument for the same rules and regulations to apply to all publicly financed homes, whether they are run by the private, public or voluntary sectors. As a condition of receiving funds from the Department, every home, whoever runs it, should be required to make much better information available to potential users or their families so that informed choice can be a reality. To maintain standards in all sectors the social services inspectorate should operate across the public-private divide. That is an important responsibility that the social services inspectorate should be exercising very strictly.
There should surely be a much greater degree of coordination at local level to ensure that public money is spent in the best interests of clients. If someone is entitled to or is receiving supplementary benefit for private or voluntary residential care and both the social services department and the client think that the same amount of money could provide a better service if differently used, perhaps they should be able to claim the money and use it as they think best.
Given the population structure, the need for residential care for the elderly is likely to continue to increase for the foreseeable future. Year by year the demand will increase. It is vital that we think carefully about how to use and develop all the elements of provision—whether public, voluntary or private—into a coherent policy of social care for the elderly who require it so that we have a good 321 meshing of the different types of care provided and standards are comparable across the frontiers of the three types of care.
That policy must ensure that the resources available can be transferred from one area of government to another, according to the needs of the individual. That is why we call attention in this short debate to our concern about what is happening now and to the potential problem for the immediate future unless proper control is exercised by the Department. I hope that the Minister will be able to tell us what control will be exercised.
§ Sir David Price (Eastleigh)
As a member of the Select Committee I wish to say a few words in support of our Chairman, the hon. Member for Wolverhampton, North-East (Mrs. Short). I nearly said "my hon. Friend" because on our Select Committee we regard each other as hon. Friends even if from time to time we may have a slight difference of opinion as is human. I can assure the House that the Committee was unanimous in everything we recommended in the report.
In developing the themes of our report I shall detain the House for a short time on four aspects. The first is to support what the hon. Lady has said and to draw the House's attention to the rapid increase in the number of payments of benefit to people living in residential care and nursing homes run by the private and voluntary sectors. In my judgment, it raises a number of important questions about the past, the present and, even more importantly, the future provision for our elderly citizens.
The hon. Member for Wolverhampton, North-East read from paragraph 70 of the report. I should like to draw the House's attention to the numbers rather than to the money. We talk about there being 7,000 beneficiaries in private rest homes in 1978. By 1984 the figure had risen to 42,500. As a proportion, in 1979, 14 per cent. of the residents in private and voluntary homes were being supported through the Department of Health and Social Security. By 1984 that proportion had risen to 35 per cent. I have reason to suppose that today it is nearer 50 per cent. That raises considerable issues for the House to consider.
I am satisfied that what we say in paragraph 72—Much of the increase in expenditure can be explained by a growth in demand"—is correct. That growth in demand is certain to continue. Again, I hope that the House takes that firmly on board. Let me give the House some figures of my own to illustrate the inevitability of that increase in demand. Let us take the demographic changes expected between 1985 and the end of the century, only 15 years hence. The percentage of people of pensionable age 65 or 60 — when men and women receive their respective pensions—will drop from 18.2 of the population in 1985 to 17.8. However, the percentage who are 75 or older will increase from 6.4 to 7.1. In absolute numbers, that is an increase of nearly half a million people.
We all know people in their 80s or even in their 90s who are more robust than many of us sitting in the Chamber, but as a general planning concept it is reasonable to accept that the older people get, the more dependent they are. Therefore, that change in the demography of elderly people is a point that the House has to take firmly on board in relation to our report.
322 One must conclude that the provision that we are talking about will need to increase rather than diminish. Therefore, I trust that, the House will: accept our conclusion in the Select Committee;Given the increasing: number of elderly people, and particularly of the very old, the demand for residential care and for board and lodging.payments is bound to continue to grow for many years to come.My second point is about the qualitative aspects of the current arrangements.
§ Mr. Frank Field (Birkenhead)
The hon. Gentleman may raise this matter on his other points, but I thought that he would do so on the first point when he talked about the numbers involved, the sums involved, and, most important, the trend. Ealier in hid speech he raised the significant policy issue about the role of the DHSS. That applies to students—should the DHSS be paying money to students, or Should that be for the Department of Education and Science? In his Vilietlgoints, will the hon. Gentleman consider whether it is approprjate for the DHSS to be paying that sort of money,or whether that should be channelled from: the DHSS budget to the local authorities?
§ Sir David Price
I can assure the hon Gentleman, whose knowledge is extensive and for whom I have the greatest respect, that that is the fourth aspect that I shall touch on. If he will forgive me, I wish to develop my points in my own sequence.
I was dealing with the qualitative aspect of current arrangements. I should like to ask these questions. Are the current levels of payment sufficient to ensure a proper standard of provision? That ties up with the next point that I wish to make. Should there be,regional if not local variations? The evidence that I. have from Hampshire suggests that costs vary, particularly when it comes to the variation in housing costs. Are we making sufficient provision for the very dependent elderly ,people? In our report we welcomed ,the Government's decision to introduce a higher rate for very dependent elderly people from 28 July. We congratulated the Government on that. But is that the end of the stoty?,Should we be more sensitive in variations of rate?` We know the reality as people get frailer and become more dependent.
Then there is the Whole question of the uneven treatment of disabled and handicapped people. We drew attention to that in our report. Hon. Members who are present, all of whom understand those matters, know that there is a big difference between the financial treatment of similarly disabled people, according to the' age at which one becomes disabled.
Another aspect of the matter 'about which I feel strongly, is, the treatment of attendance allowance as income in the assessment of supplementary benefit. I have been campaigning for many years on that matter. I feel extremely strongly that attendance Allowance should never be treated as income. We won the that with the Treasury. We got it to accept that attendance allowance should be tax free, just like mobility allowance. Those are two allowances that are nothing to do with income. They are to do with helping people who are severely handicapped to live with their handicap. I believe that these allowances are in a different' category from.normal income support. I have argued the case in the House for many years. I regard what is now happening as a retreat. from what I thought was territory that we had conquered for keeps, but one knows that in life no victory is ever complete.
323 Thirdly, I draw the House's attention to the setting and maintaining of standards in private rest homes and nursing homes. I am sure that the whole House agrees that we must weed out the cowboys. We have yet to see the fully beneficial effects of the implementation of the Registered Homes Act 1984 and the Nursing Homes and Mental Nursing Homes Regulations 1984. We welcomed the reassurances of my right hon. Friend the Minister for Health and my hon. Friend the Minister for Social Security when they gave evidence to us. They were absolutely clear. Are the levels of payments, particularly in the more expensive parts of the country, sufficient to support those purposes? I wonder whether there may be a more positive role for the DHSS as inspectors rather than local authorities, not purely in a policing and monitoring sense, but in a positive sense, similar to the role of HM I in schools. I leave my right hon. and hon. Friends with the thought that there might be a constructive as well as a purely monitoring role for this Department.
Finally, 1 should like to raise the wider aspect of how the provision in private rest homes that we are discussing today ties up with all the other aspects of our national provision for the elderly. The hon. Member for Wolverhampton, North-East drew attention to the matter too. We said in paragraph 75 of our report:A clear national policy for the support of the elderly inside and outside residential care must be devised.It is my personal view that we cannot have too wide a spectrum of arrangements for caring for the elderly because every elderly person is an individual. In every family circle, every person is different. It seems to be a mark of an advanced and generous society to have as close to infinite a range of arrangements as we can obtain. I do not believe that there is any uniquely correct method of provision. On the contrary, I invite the Government to take the lead from St. John's gospel, where we read:In my Father's house are many mansions.I want to see many mansions. My own experience, and my own gut instinct, tells me that the preferred mansion of most elderly people, if not all, is their own home.
Therefore, in seekingA clear national policy for the support of the elderly",I have a bias in favour of care in the community as against institutionalised care, whether public or private. In my judgment, all current financial arrangements favour institutionalised care. My plea to the Government is to redirect our financial arrangements so that the provision between institutionalised care and care in the community is at least neutral. If I carry the House with me so far, my plea must mean more public money in support of care in the community where most of the care happens today. Put another way, I ask the Government to support personal choice for the dependent elderly.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
I congratulate the hon. Member for Wolverhampton, North-East (Mrs. Short) and the hon. Member for Eastleigh (Sir D. Price) on their work as members of the Select Committee on Social Services. The Committee's fourth report is a valuable document and I look forward to studying the other aspects of the report later.
It is correct that in today's debate we should examine the sections of the report which deal with private and voluntary residential care for the elderly. I believe that expansion is not a bad thing, but since 1980 there has been 324 a disturbing element of unplanned growth. There is a difference between necessary expansion and the way that that growth has taken place. Indeed, the Government would probably admit—privately, if not publicly—that that is what has happened. They have had to respond and react to events, and they have responded — unwittingly and without any design intended—in a way that has compounded the problem.
I am mystified as to why the Government decided to extend supplementary benefit to residential care against the long-established tradition of local authorities providing part III accommodation. I was more closely involved in the 1983 decision to impose categories and local ceilings. The inevitable consequence was that expenditure spiralled. Paragraph 72 of the Select Committee report states:In other words, landlords raised their prices to meet the limits. It is easy to speak with hindsight, but it does seem remarkable that the DHSS did not foresee what would happen.Many of those landlords must have seen the Government coming. The Government can be charged with having presented themselves as a soft target.
§ The Minister for Social Security (Mr. Tony Newton)
I was tempted to intervene during the speech of the hon . Member for Wolverhampton, North-East (Mrs. Short) earlier on this point. One point which has not been recognised in what has undoubtedly been an intractable and difficult area of policy for many years is that the previous regulations, which were replaced in 1983, contained a completely open-ended provision for charges to be met without limit where it was unreasonable to expect the claimant to move. The fact that that totally open-ended provision was exploited by many organisations, and was advertised freely, led us to make the changes. To suggest that a provision of a tighter variety was replaced by the present provision is an over-simplified reading of the regulation.
§ Mr. Kirkwood
I agree with the Minister that this is a complicated area of policy. However, he should have looked twice before he authorised the new regulations. I hold no great brief for those who criticise private residential homes, as there are people on the make who make money unscrupulously, However, the vast majority — certainly in my part of the country — are not so minded. It is inevitable that landlords, when they see that the local limit is higher than their charges, will charge more for the better service that they believe they are providing. They consider that it costs more money to provide the better service.
§ Mr. Frank Field
The Government would have been wiser to keep the existing regulations to meet charges, provided that they were not unreasonable. The unscrupulous landlords, who have exploited the system, would not have been told at what level they could fleece taxpayers.
§ Mr. Kirkwood
I agree with the hon. Gentleman. It may have been necessary to change the definition of what was reasonable or unreasonable at the time. However, matters could have been controlled in a more sensible way.
325 When the system was changed again, by categorising the limits by handicap, a host of problems resulted. For example, in many cases, limits turned out to be inadequate and we had to resort to transitional protection. There is now an exceptional hardship category and there is the problem of the elderly higher rate which is payable only if people are disabled before retirement age. Whenever the Government try to change and ameliorate the system, they compound the problem.
Demand has continued to increase. In his evidence to the Select Committee the Minister referred to some possible future problems. However, I am worried about the present trends. In his evidence, the Minister said:This demographic trend produces foreseeable very, very large increases in demands on what is currently social security expenditure, of a kind which … the Government concluded we could not confidently be sure that they could be sustained into the next century.That statement together with the fact that the Government have had the benefit of the joint working party report published in 1985 and the Ernst and Whinney report published in 1986, must lead us to expect a clear policy statement of the Government's intentions. The need for that statement is reinforced by the fact that the Social Security Bill is about to complete its final stages. The Select Committee is correct to state that it is wrong for the Government to leave this area untouched and for the Minister to hide behind a statement that the regulations provide enough flexibility to cope with the present position. The Minister did not make it clear that if he wanted to change the position and if the need for substantial change arose, he would be able to do that under the Social Security Bill. In the aftermath of the important Select Committee report the House should have a clear answer from the Government on that point.
I am worried about several points. I believe that choice is a good thing. The hon. Member for Eastleigh alluded to that point in his remarks. However, I am worried that the direction of board and lodging payments and residential care runs counter to the Government's policy on community care. Local authorities are short of finance, and it is easier for prospective applicants to opt for residential care even if their needs do not show that that is necessary. There is now almost a financial incentive to opt for residential care, and that is compounded by the fact that domiciliary support is more difficult to come by these days. Although the element of choice may be present in theory, in practice it is disappearing.
The proposal cannot be an efficient use of public money because there is no assessment of need. The test for residential provision is simply one of supplementary benefit, not of a level of dependency. That cannot be an efficient and sensible use of public money.
I also believe that the system of funding is inequitable. Within the disregards operated by local authorities, there is a capital disregard level of £1,200 before they start charging. We know that the DHSS, under the supplementary benefit regulations, has a capital disregard of £3,000. How can that be fair? The weekly personal allowance that local authority part III accommodation claimants receive is £7.75. The DHSS personal weekly allowance for people in the same homes is £9.05 per week. The funding is inequitable. If the Government are to 326 continue the system, that inequity must be redressed. The Government must also consider the implications for the home care and meals on wheels services.
The Government have three choices, and these were referred to in the joint working party report. The first is that all the charges should be put on the system of supplementary benefit for residential care. That would appear to be the way that the Government are drifting. I use that word advisedly because they are not making a positive decision to move in that direction. Secondly, the whole charge could be put on the local authority.
Thirdly—I hope that the Government will give active consideration to this—the board element could be paid by the DHSS, which has the machinery to do so efficiently within reason, and the care needs could be assessed by the local authority. I believe that that is the most fruitful way forward. There are real problems about assessment, and the system of assessment must be extended. There are also real problems about charges. As the Ernst and Whinney report pointed out, the market is sensitive to the DHSS limits and claimants face widely differing circumstances. Nevertheless, I believe that the general direction that I have described is the one that the Government should take. I hope that they will act quickly.
§ Mr. Michael Meacher (Oldham, West)
First, I pay a warm tribute to my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) and to other members of the Select Committee on Social Services—I recognise the consensus of the Select Committee — for drawing attention in the fourth report to the serious and disturbing problems becoming increasingly apparent in private and voluntary care provision for the elderly as a result of the Government's differential approach to funding between the public and private sectors. I am not sure that I can follow the hon. Member for Eastleigh (Sir D. Price) with a biblical reference, as I omitted to look one up before the debate, but I liked his line about the redirecting of money. I would go further than making it neutral as between residential and community care, but the hon. Gentleman was right to make that point.
I strongly endorse all that my hon. Friend the Member for Wolverhampton, North-East has said. She eloquently described the sharp zig-zags of Government policy in the past six years as they have twisted and turned from one device to another in an attempt to reconcile the irreconcilable—that is, to use public money to provide a major boost for the local commercial market, while at the same time meeting need and containing public expenditure. In my view it has always been clear—the history of the past six years has conclusively shown this to be so that those are fundamentally incompatible objectives. Since 1980 the Government have shifted from one extreme to the other, with policy reversals cancelling previous initiatives, but they seem unable or unwilling to learn the basic lesson that no amount of tinkering with the system can make the private sector the main provider of services, while at the same time ensuring that limited residential provision is strictly allocated to meet priorities of need.
We believe that the Government's fundamental philosophy and approach are at fault. Contradictions show through at every stage of policy evaluation in the past few years. As my hon. Friend the Member for Wolverhampton, North-East pointed out — it is important to clarify the Minister's reference to this—in 327 1980 the Government permitted supplementary benefit board and lodging allowances to be paid at a rate commensurate with local residential charges, with power to pay more in particular circumstances. There was no capped limit, but a measure of discretion, and local officers are perhaps best placed to exercise that discretion while ensuring that local charges are properly met. When that discretion became more widely exercised, the Government's overall commitment to limiting expenditure led them to impose a ceiling on the amount that could be paid and to introduce local variations. Because they did not want any forced removals from homes, the new level in each locality corresponded to the highest reasonable charges in that locality.
That compromise in November 1983 produced the worst of all possible worlds. Many proprietors levelled up their charges to the local limits and many new homes were opened as people who did not necessarily have any caring background or experience saw the commercial potential of doing so. At the same time, many local authorities stopped sponsoring residence in the private sector. Some withdrew from existing sponsorships and some even planned to sell off complete local authority premises to private owners. As if all those no doubt unintended consequences were not enough, expenditure on board and lodging in private homes rose nearly fivefold in two years to £190 million in 1984.
Not before time, in April 1985, the Government introduced a new system abolishing local limits and re-establishing national limits, but this time differentiating according to age and the type of disability of the claimant. It quickly became clear, however, that there were significant drawbacks inherent in the new system. The limits were set too low for certain types of care, especially care for the more dependent elderly people and for multipally handicapped young people. The limits were set on a national basis without any regard for local or regional variations in cost, thus preventing local authorities from paying for the extra care needs of some elderly claimants through topping-up arrangements and also discriminating against elderly people who became physically disabled after pension age.
The Government implicitly acknowledged the validity of those criticisms in their latest amendment to the regulations last month, which proposed a higher limit for Greater London and for severely dependent elderly people. Although that change is welcome, it falls well short of meeting the criticisms. For example, the Ernst and Whinney report shows that, although average gross unit costs in the private sector are £117 per place per week, they cover a huge range from £36 to £247 per week. To compress that range into a single national limit, albeit with a variation for Greater London, does not, and cannot begin to, reflect local economic realities. More fundamentally, none of the recent adjustments in any way mitigates what I regard as the real case against the Government's general policy of discriminating in favour of the private sector.
First, it is profoundly wrong that huge public subsidies are now provided for private residential care without any assessment of residential need in terms of physical or mental frailty. Dependency is not a criterion for entry in the private sector. As has been pointed out, public money will be spent on people whose need for residential care may be minimal, provided that they qualify for supplementary benefit. That is not just wrong in terms of priorities. It is 328 also highly wasteful. The efficient use of public money requires assessment whether residential care is really needed or whether support systems can be provided to keep the person functioning within the community.
Secondly, it is ludicrous that while local authorities are forced to budget within overtight constraints because of rate support grant cuts and rates penalties, including cuts in community care initiatives, public money is being sucked into private residential alternatives on a demand-led basis. It is absurd that while local authority development of community care is completely hamstrung for lack of funds, private residential provision for the elderly has doubled since 1979 and supplementary benefit payments for people in such accommodation have increased nearly twentyfold.
Most significant of all, when public expenditure is tight, it is a grotesque misallocation of funding that the proportion of private residents financed through supplementary benefit has nearly trebled since 1979 to more than 40 per cent. now. In terms of the Government's supposed policy for the family, this has the ironic effect not just of making it easier for families to dump their relatives in homes, but of providing a financial incentive for them to do so because arranging and paying for domiciliary support is so much more difficult.
Thirdly, there is inequity in funding between the private and public sectors. I shall not make much of this point, but, for example, the capital disregard for residents in the private and voluntary sectors receiving supplementary benefit is fixed at £3,000 whereas local authorities can disregard only £1,200 before charging.
Fourthly—this is a more substantive point—Ministers constantly defend the private sector as reflecting greater individual choice. I am all in favour of choice in principle, but in fact the huge mushrooming of subsidies for the private sector at the expense of local authorities has diminished overall choice for the elderly.
In 1984 expenditure per head of population aged 75 and over on local authority home care services was only 79 per cent.—less than four-fifths of its level in 1978–79. For meals on wheels it was only 85 per cent.
That suggests that the choice has been between a well-funded and easy-to-obtain private residential place, and a restricted and hard-to-obtain home help service. I doubt whether that is in accordance with the priorities of many hon. Members. It is estimated that it will cost more than £300 million net to bring those services back to their 1978–79 level. It is difficult not to see the shortfall as having been badly aggravated by increases in supplementary benefit payments to private residents, over the same period, of £184 million.
Those are all major reasons why we believe that the whole thrust of the Government's residential care policies is wrong-headed and inefficient and actually distorts their own declared community care objectives. Even within the parameters of the Government's own policy framework —which we do not accept—the present policies have serious defects which the Government must address before Parliament votes to continue the current funding arrangements. After all, that is the purpose of a debate on the Estimates.
§ Mr. Frank Field
I have followed with interest my hon. Friend's comprehensive attack on the development of Government policy. As we are unlikely to convince the Government tonight, can we register the points of 329 agreement? Is my hon. Friend saying that there is support on both sides of the House for a change that will ensure that people will not have access to the private sector and pick up supplementary benefit payments unless they are deemed necessary for that service by the local authority?
§ Mr. Meacher
My hon. Friend, whom I did not consult about the preparation of my speech, has anticipated one of the points that I intended to make. I very much agree with him and endorse what he said, and shall comment more fully towards the end of my speech.
The most obvious example of serious defects in the Government's policy is the fact that the care of all supplementary benefit funded residents — there are 42,000 according to a recent parliamentary answer on 10 February—is put in jeopardy if the home owner decides to increase the fees, as he is entitled to do. Indeed, there is now some evidence of evictions.
I wish to quote from the extremely good report by the National Council for Voluntary Organisations that was published last year, and to that extent is slightly out of date. It refers to the report of Counsel and Care for the Elderly "Every solution creates a problem" — an interesting title and not entirely inaccurate in this context—and gives the example of a 93-year old woman whose only relatives are distant cousins and who is paying her own fees of £250 a week in a small nursing home. The home informed the family that it would evict her if its full fees were not met by a fixed date. A charity made a holding grant of £400 to give the family a small breathing space. Applications were made to other funds, but the outcome has yet to be decided. I hope that it is decided satisfactorily, but I doubt whether such a precarious provision could last indefinitely.
Another example from a concerned Hampshire social worker showed that one home had increased its fees from £150 to £175 a week and had told the elderly resident on supplementary benefit that she would have to leave if she could not make up the difference. Relatives have stepped into the breach for the time being, but the situation cannot last indefinitely. That is a serious problem. I fear that there will soon be reported evictions, if they have not already occurred.
The quality of life of residents may be markedly affected if home owners, who probably do not wish to evict residents, decide to cut facilities rather than increase fees. In addition, the turnover in ownership of homes may sharply increase. I note that in Norfolk, for example, a fifth of private homes either closed or changed hands during one year recently. A different regime may profoundly alter the suitability of a home for its residents.
A rather more paradoxical result of current policies is that there is clear evidence that they are defeating their own purposes. Most owners of private homes have responded to the new supplementary benefit limits by refusing to admit supplementary benefit claimants. The NCVO reports that a spokesperson for the Registered Nursing Homes Association in Surrey said that since the limit was introduced there had been no admissions of people on supplementary benefit into nursing homes in the south-west. Before the limit it had a policy of admitting 50 per cent. DHSS-funded patients, but it says that it can now no longer afford to do so.
330 The NCVO report, in another example, showed that an investigation carried out by the Lewisham and North Southwark health authority revealed similar results, in that at the end of July 1985, 59 elderly patients who had previously been discharged to private nursing or residential care homes were being kept in hospital because they could not afford to pay the difference between the charges and the amount available through supplementary benefit.
It is a ludicrous position where, according to Counsel and Care for the Elderly, up to one third of the 50,400 elderly people in hospital geriatric wards want to leave, are fit to do so, but cannot afford nursing home care. Few private nursing homes charge less than £220 a week, compared with the latest limit for nursing home care of the elderly of £180. It leaves a weekly deficit for the patient or family of at least £40 or £50 a week, and most cannot find that sort of money. It is ludicrous to have such a policy when the cost borne by the state for a bed in a London geriatric ward is £300 to £320 a week, and when for an acute bed for patients who require more intensive nursing, the cost can be as much as £400 to £500 a week.
Another serious weakness in the Government's financial framework is that there is no funding for very short-stay care. The DHSS will not, for example, fund a weekend stay for severely dependent elderly relatives, even though the families caring for them often reach a crisis point and can continue, as we all wish them to do, only if respite care is covered in an emergency.
For all those reasons, the Opposition are highly critical of the morass of Government policy in which they are currently bogged down. Even within the Government's own terms of reference, which I have said we do not accept, it is self-defeating. Presumably even the Government are disturbed that the consequence of their policies on private homes is to force many of them into making economies in the standards of care provided, to refuse to admit elderly people who are dependent on supplementary benefit, to close high-cost homes—even if they are good — and to restrict plans for new development.
Even within their own policy framework the Government have so far failed to implement several of the recommendations of the joint central and local government working party report published last year. If the Government are determined to make private care a spearhead of their provision—that is their policy, not ours — they should set a negotiated rate that is less inflexible than a single national limit, even with the variant for central London. They should pay for pensioners who are mentally ill or physically disabled at the same rate as they pay for such persons under pension age. They should pay for people with multiple handicaps in residential homes at the same rate as they pay for similar levels of care in nursing homes. They should provide for topping up by local authorities for residents requiring high levels of care. They should pay for elderly people taken into residential care for short stays and at short notice to provide a break for carers under pressure.
All that is to remedy deficiencies in the application of current Government policy. Our real objection is that the policies are thoroughly misguided at root. Our policy involves a radical change of course. We believe, as a fundamental axiom, that care provision for the elderly 331 should be determined by need and not by personal income or the adventitious availability of supplementary benefit. That has several implications.
§ Mrs. Edwina Currie (Derbyshire, South)
Will the hon. Gentleman make it clear whether he supports the continued growth of private sector residential care for the elderly, or whether he wishes to see it shut down?
§ Mr. Meacher
If the hon. Lady listens to my remaining remarks, which will be brief, I think that she will hear the answer to that question. I recognise that it cannot be closed down. A large number of elderly people are in the private sector. However, I believe that it should not expand. For those who enter in future, I believe that access should be on the basis of need, where possible, and not on the basis of personal income, which tends to restrict it to the better off. Standards of supervision and inspection should be tighter.
Community care plans should be developed, based on the systematic identification of need, both among the elderly and other dependent groups in the community. Where access is determined by need, the public sector should be able to expand both residential and domiciliary care free of the present massive and artificial juggernaut of financial controls that inhibit the development of a rational and efficient system of community care.
Local authorities' assessment arrangements for admission to their own homes—this was referred to by my hon. Friend the Member for Birkenhead (Mr. Field)—should he extended to those claiming supplementary benefit board and lodging allowance for residential care in private homes. Only those genuinely in need of residential care would receive support. Savings could be used to finance alternative and more effective forms of community care.
Closer inspection and supervision of private homes is necessary to improve the quality of those that are substandard, to prevent abuses, skimped provision or actual maltreatment— I readily agree that this occurs in a small minority of cases—and to ensure that there is no excess profit rate per resident. The hon. Member for Derbyshire, South (Mrs. Currie) intervened on that earlier.
There needs to be a fundamental redirecting of care. The Government's present policies are not targeted on need, they are a wasteful and inefficient distortion of the true function of supplementary benefit, and even within their own right they are counter-productive, because of public expenditure cuts, in excluding many elderly people for whom the provision is intended. The Government's obsession with the privatisation of care has turned out to be as defective and objectionable as the Fowler review's disastrous attempt to privatise welfare generally. The position must be reversed. It will be soon when the Government are overturned.
§ Mr. Roy Galley (Halifax)
I pay tribute to the hon. Member for Wolverhampton, North-East (Mrs. Short) for the way in which she introduced the debate and for her competent summary of the Select Committee's report. It is important for me to say that, and it is genuinely meant. My hon. Friend the Member for Eastleigh (Sir D. Price) said that all members of the Select Committee were, generally speaking, hon. Friends. I hope that that is the case. However, in view of the way our revered Chairman 332 looks at me in Committee, I feel that she does not always regard me as an hon. Friend. Nevertheless, I believe that she introduced the debate in a competent and helpful way.
The jarring note that has been introduced into the debate by the hon. Member for Oldham, West (Mr. Meacher) is unfortunate, because we have had a constructive debate so far. It seems that the hon. Gentleman is unable to stand at the Dispatch Box and be graceful or constructive about our proceedings.
In the comprehensive summary of the report by the hon. Member for Wolverhampton, North-East there were one or two nuances with which perhaps not all Committee members would agree. They may not agree with her interpretation of the contents of the report. Committee reports are so skilfully worded by our competent Clerks that a variety of interpretations is possible.
§ Mr. Nicholas Winterton
It is important that the House should understand that the reports are not drawn up by Clerks. They are drawn up by Committee members. We, not the Clerks, are responsible for the wording of our reports. I hope that the House and those beyond the House realise that.
§ Mr. Galley
I am grateful to my hon. Friend for correcting me on that important point. There are times when the skilful wording of the Clerks assists the Committee in coming to an agreed conclusion. One must recognise that fact.
The advantages that result from the present system have not been emphasised in the debate. One can understand the concerns about the conflict with community care policy that the present arrangements present. One cannot necessarily put a price on the important element of freedom of choice. The system that has developed over the past five or six years has meant a variety of provision that has provided a greater freedom of choice for many elderly people and has reduced pressure on the budgets and staff of many local authority social services departments. That freedom of choice should be encouraged.
Freedom of choice and value for money will be increasingly important because of the demographic pressures to which my hon. Friend the Member for Eastleigh so eloquently referred. It is clear that an integrated national cost limit system must be applied to residential care for the elderly. If such cost limits are set at a realistic level, with adequate flexibility for transitional arrangements and for special care additions, we should be able to obtain a balance so that the private sector is adequately reimbursed, no one milks the system, appropriate provision is made for the elderly, and variety is provided, by public and private sectors in partnership, to assist the elderly who require residential care.
The growth in the level of expenditure has rightly led to great concern about cost benefit analysis. There is a requirement for the protection of the elderly in residential care and at the same time for the safeguarding of taxpayers' money. That has led to sustained calls—we have heard echoes in the debate— for a co-ordinated system of assessment. The proposal appears to be for a multi-disciplinary approach involving social workers, the DHSS and other appropriate voluntary or statutory agencies, with the objective that local authorities should, in essence, determine whether people in private residential homes should be eligible for supplementary benefit support.
333 I must inform the Under-Secretary of State, my hon. Friend the Member for Huntingdon (Mr. Major), that I have qualms about a comprehensive assessment proposal such as that under consideration. It is one of the main recommendations from the joint central and local government working party. It will introduce a bureaucratic straitjacket and mean that people will need a local authority ticket for a residential place. That would restrict freedom of choice, unless people could afford their residential places.
Some people choose to live in a residential home because they want to be looked after, and they can afford to pay for it. Others, who are unable to pay, would need local authority approval before being able to take a residential place. A tight assessment system, such as has been suggested, would reduce the latter group's freedom of choice, so it would be somewhat discriminatory.
There may also be problems for people who could initially afford a residential place but whose funds became exhausted. They would then have to be assessed for supplementary benefit purposes before being given support. The proposed assessment system would produce several anomalies.
It must be possible, within an integrated national system, to cope with the needs of the elderly and to preserve existing choice. We must equate more clearly the rules for supplementary benefit support in private and local authority accommodation. That especially applies to the rules on capital. My hon. Friend the Member for Eastleigh rightly emphasised that we must treat fairly people who are elderly and handicapped vis-a-vis those who are younger and handicapped. We do not need complete local authority control of residential care.
It is important, however, that local authorities should have and should develop a role in monitoring accommodation and standards of care in the private sector, as happens now, but we need a coherent and consistent pattern of inspection. It is, however, unacceptable that some local authorities, perhaps as a result of hostility to the private sector, operate needlessly exacting standards, which are often much higher than are applied to their own accommodation, for private sector provision.
There are sometimes differences between one local authority and another in the standards required of residential homes even in adjacent areas. The same is true of nursing homes and the involvement of health authorities in their inspection. There may well be a case for a more independent inspection body covering residential and nursing homes than the public provider of residential care inspecting private providers.
The high level of residential care provision which is funded by supplementary benefit highlights the dangers of an oversimplified analysis of expenditure trends. I hope that the Select Committee's report avoids any such oversimplification. Much of the increased support for elderly residential care has transferred some local authority personal social services expenditure to the social security budget, although it is difficult to assess how much. If the money had been allocated to personal social services, local authorities might have been able to choose to spend it in other ways, but much of it would have had to be spent on services for the elderly simply because of demographic pressures.
334 If we analyse projections of personal social services expenditure, we have to take that factor into account. Taking crude social service expenditure figures and arguing that it has not increased sufficiently is nonsense if no regard is paid to the fact that a substantial part of the £280 million of social security spending is on residential care. Figures for social services expenditure in the Select Committee's fourth report must be seen in that light.
Such considerations also emphasise the need for the Department, when presenting its figures to the Select Committee, to demonstrate the interconnecting elements of its budget provision. That applies to the relationship not just between personal social services and social security, but also between hospital services, family practitioner services, social security, personal social services and the implications of many of those heads of expenditure for community care. The simplistic number crunching in which many people have recently indulged is not an adequate guide to what is happening in residential care or in any of the DHSS's other areas of responsibility.
There must be a more sophisticated approach. We must consider how many patients are treated, how many have the advantages of residential care and how service provision is improved. The present variety of service provision and the methods of funding it is to be encouraged and cherished rather than condemned, as it has been by some hon. Members today.
§ Mr. Dafydd Wigley (Caernarfon)
I congratulate the hon. Member for Wolverhampton, North-East (Mrs. Short) and her Committee on this timely report on a matter of growing concern to hon. Members of all parts of the House. The problem affects us in our constituencies. None of us can escape the present demographic changes and the problem of how to help the elderly population.
In another context I have drawn the attention of the House to how the problem was brought home to me in my constituency. When I first entered Parliament 12 years ago, all but two of the 36 residents in the old people's home in my constituency were able to go for a walk down to the village, for example, to buy tobacco, newspapers and sweets. Only two were stuck in the home. Now, all but two are bound to the home.
That change reflects what has happened in the community. The population has aged and local authority homes for them have undertaken a function which used to be undertaken by geriatric wards in hospitals. Those wards are now cram-packed and cannot cope. The pressure had to be relieved in some way. The growth in the number of private homes is a response to that pressure, which has developed since 1978. A financing mechanism in response to that pressure has also become available.
If Ministers had been told in 1978 or 1979 that the cost of providing private residential care through the supplementary benefit system would increase from £6 million in 1978 to £280 million now, I am sure that they would have had apoplexy, just as they do now when we say that such money is needed to help with care in the community policies. We advanced that argument in our debates on the Disabled Persons (Services, Consultation and Representation) Bill.
It is right that we should ask how the money is being spent and whether it is being spent in the most effective way. Paragraph 40 of the Select Committee report says that from 1980–81 to 1984–85 there needed to be a 2 per 335 cent. per annum growth in personal social services expenditure, but that there was only a 3.4 per cent. growth in real terms during the five-year period. Paragraph 41 says:Sixty-four local authorities fell short of this target, so in three authorities out of every five, there is reason for concern about the adequacy of the growth of provision.That translates into the balance of places in homes.
If we consider the figures for local authority homes, we see that in 1979 there were 129,000 places. That figure increased to 135,000 in 1984—a relatively small increase given the tremendously increased pressure in this sector. In the voluntary sector the number of places has increased from 37,000 to 43,000, which is a slightly greater proportion of growth, but is still relatively small. The number of places in private homes has almost doubled, from 34,000 to 66,000. This shows how the problem has been met by using the supplementary benefit system, and perhaps using it in a manner that was not thoroughly considered when the changes took place. The proportion of places in private homes or based on supplementary benefit increased from 15 per cent. to more than 40 per cent. during that period. That underlines the problem.
We all know the range of problems faced by the private homes in our constituencies. North Wales is a beautiful area, and it is easy for someone who has been a car mechanic in Liverpool and has been made redundant to open a home for elderly people in a beautiful part of Gwynedd. Some people have done it well, without any experience, but the standards of homes, to say the least, are variable. I have grave doubts whether some of them should have been allowed to open. A problem arises from the mushrooming of homes in, for example, seaside towns. Substantial pressure is then put on the social services departments and on the health authorities in those areas.
A similar problem has been reported to me of an elderly person who went into a private home as a relatively able-bodied person and was then taken seriously ill, taken to hospital, and the private home did not want him back. Inevitably, that situation will arise in some private homes. Whether it is stated in such specific terms is another matter. There is a danger of some people feeling insecure. I acknowledge and accept that homes for elderly people in the private sector play a role in a balanced community, provided that they meet the necessary standards, which must include the provision that when an elderly person enters a home, that is his home. We do not kick elderly people out of our domestic homes. We do not throw out a grandmother or an uncle when they become ill because they are too much of a burden. Illness cannot be accepted as a burden in private homes for the elderly.
§ Sir David Price
Does the hon. Gentleman recognise that the problem to which he draws the attention of the House also exists in part III accommodation? Many of us have had experience of people who have been in hospital, especially in a geriatric ward, for any length of time having their places in part III accommodation filled because of the demand for it. It is difficult to get them out of the geriatric hospital and back into alternative part III accommodation. That applies across the public and private sectors.
§ Mr. Wigley
I accept that it is a problem. The problem also arises on the other side. When elderly people go into hospital, the hospital often wants to move them out without there being any proper facilities for them to go to. They are moved like ping-pong balls backwards and 336 forwards. We all know of such cases. The elderly patient's relatives come to us and say, "What can you do to help this person who has become ill or disabled and who is caught in that position?"
I have no doubt that the public policy subscribed to by the Government and by other parties in the House to try to maximise care in the community is right for that reason. The most helpful way of catering for people is to have flexible support services that can be built up as necessary to help the carers in their homes and their family environment.
The Ernst and Whinney report mentions problems with standards. How do we measure standards? I should mention the costings on which the places in private homes are based. In the Ernst and Whinney report, the cost per place in determining the supplementary benefit ceiling has been based on the shared room concept, but the January 1986 circular issued by the Government, entitled "Residential Homes — Guidance on Standards of Accommodation" which makes a cross-reference to the code of practice entitled "Home Life" states:While most current and future residents will prefer single bedsitting rooms, some double occupancy rooms may still be needed, for example for married couples.The emphasis is on single rooms. That defines the standard. It worries me that the supplementary benefit figures have been based on costings for shared rooms. A problem exists there which the Government have not fully addressed.
The Social Services Select Committee, probably referring to evidence submitted by the parliamentary panel on personal social services, drew attention to the spread of cost and the tremendous range of costs for old people. The Committee mentions figures from £51 to more than £200. That highlights the differences. How does one obtain a measuring rod for what is proper value and a proper standard with that enormous spread of costs? It is a problem that we have not properly addressed, but we must. We must find a way of setting up a flexible system that caters for disabled and severely disabled people.
In a recent statement on the uprating of the board and lodging allowances, the Minister acknowledged the special needs of some groups of people over pension age, through the creation of new categories of payments. However, he did not extend this recommendation of need to those under pension age. The limit for those people remains at £180, without even an uprating to allow for inflation.
The Spastics Society has underlined the problem that it faces when it tries to help such people through direct provision. It said in a letter to me:For many younger multiply handicapped people f180 still falls far short of meeting the costs of their care. The Spastics Society is increasingly working with this group of more profoundly handicapped people whose needs were not recognised in the past when there was no alternative to large institutional care.The fee in Spastics Society units is about £300 a week.
We need a system that allows for variable costs. The Government have responded to representations by the Spastics Society and suggested dual registration. For social reasons the Spastics Society does not wish to accept a dual registration system. The society suggests that the answer might be for more profoundly handicapped people to be able to claim the nursing home rate without having to live in nursing care. When the Minister replies to the debate, I hope that he will respond to that proposal, which 337 has been with his Department for several weeks. He knows the difficulty faced by the Spastics Society, and I hope that he can respond to the specific and practical suggestion that it has made.
In Wales, with the all-Wales policy for integrating mentally handicapped people into the community, we are witnessing developments in community care. We have recognised especially the need for close liaison between the providers of services, whether they are the health authorities, the local social services departments or the voluntary sector. For that reason, I respond warmly to some of the recommendations made in the report. Recommendation 31 states:we recommend that the Government analyse closely the interaction between health service finance, local government finance and social security with a view to ensuring that joint planning does not founder because of inadequate knowledge by one sector of government of the implications of its actions on community care projects and on the joint planning process.That is very important. The more that we see in Wales and in other areas where progress has been made in that context, the more we become aware of a need to move in that direction.
We are faced with some difficult decisions if we wish to obtain a finely tuned system which maximises choice, which maintains standards and freedom, which ensures that provision is made on a community-based level wherever possible and which is neutral and does not push people in certain directions. I spoke a moment ago about freedom of choice, and that is something we need. It should not lead families to dump old people in semi-institutional care. We should maximise choice. Side by side with supplementary benefit payments we should consider how such services can be financed in the community.
This report must be considered in the context of our debates on the Social Security Bill and the Disabled Persons (Services, Consultation and Representation) Bill, and the debate on care in the community that we had a few months ago. As has been suggested by several hon. Members today, the care element should be considered over and above, and aside from, the board and lodging element. That may be the way forward. The care element should be flexible and be directed appropriately. Whether a person is living in his own home and maintained by carers in the community, in a private home, or in a local authority home, additional resources should be made available to meet the needs of caring. In answer to the point made by the hon. Member for Eastleigh (Sir D. Price), I should say that flexibility might encourage people to keep places for those who may become more profoundly disabled as years go by.
I hope that the Government will take on board some of the very important points made by the Committee and that the debate will not end at 7 o'clock without some progress having been made.
§ Mr. Nicholas Winterton (Macclesfield)
I am delighted to follow the hon. Member for Caernarfon (Mr. Wigley). He made a most constructive and helpful contribution. It is rather sad that the Opposition spokesman, the hon. Member for Oldham, West (Mr. Meacher), did not set a similar example. Setting aside the party political polemic, the prejudice and the dogma in his comments, he put 338 forward some sensible ideas which merit consideration by the House and by my hon. Friend the Under-Secretary of State who will respond to the debate.
I congratulate the hon. Member for Caernarfon on his useful contribution, which highlighted some important areas of concern. Since being elected as the hon. Member for Macclesfield in 1971, I have visited the part III homes in my constituency at least once, and sometimes twice, each year to see exactly what is happening and to hear from the staff and the residents. Therefore, as a member of the Select Committee on Social Services, I am well aware of the opinions of residents of part III homes and of the problems faced by the staff of county residential homes.
The hon. Gentleman was also right to say that in recent years the health and condition of the people living in part III hopes has dramatically changed. I served for six years on Warwickshire county council and used to visit part III homes in that county. The majority of elderly residents were mobile; very few, if any, were incontinent; and none was doubly incontinent. The position has changed dramatically during the past 20 years, because, of course, the people who are now residents of our part III homes were 20 years younger then, and they are now very elderly. I do not think that I will mislead the House if I estimate that in part III homes in Macclesfield two thirds of the residents are singly incontinent, and quite a high proportion of them are probably doubly incontinent. Those part III homes were not designed for people needing that level of care, who, because of their health, place an immense burden of care on the staff who work in the social services departments of the county councils.
We are faced with an increasingly difficult and complex problem. I agree with the hon. Member for Oldham, West that perhaps the supplementary benefit eligibility for entering a private or voluntary residential nursing home should be based upon need, not just upon the availability of resources for that person. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) also picked up that point. I hope that my hon. Friend the Minister will turn his attention to this matter in his reply.
If I may be parochial—perhaps it is not inappropriate to be parochial in the House occasionally—I shall refer to the importance of the elderly in my area. The elderly top the housing list of Macclesfield borough council. Of the 3,400 on housing waiting lists, 1,125 are elderly people requiring specialist accommodation specifically constructed for them. I highlight that statistic to show the level of concern about this matter in many areas of the country, not least in my area, which is a progressive area where the number of elderly people is increasing dramatically. That places increasing burdens upon the hospital facilities required for geriatric accommodation, and produces a requirement for the building of more specialist accommodation, and for more domiciliary care.
The hon. Member for Oldham, West raised an important issue when he said that we must ensure that more specialist staff are available to help people to remain in their own homes. I agree with that.
The hon. Member for Caernarfon was the first in the debate to highlight the position of carers in our society —those who look after elderly relatives—who take it as their personal and voluntary responsibility to look after someone they have known for many years who has become extremely old and needs to be looked after at home. Those people have taken a great responsibility upon their 339 shoulders, removing a considerable cost which otherwise would have fallen upon the state. I hope that additional resources can be directed towards carers, who play a unique and most valuable role. The hon. Gentleman has done the House a service by raising that matter so clearly.
Some Opposition Members have implied criticism of the private and voluntary sectors and of their role in making provision for the elderly in our society. That is unfortunate, because it is appropriate that the private sector should put capital into the provision of accommodation for the elderly, whether it is straightforward residential accommodation or specialist nursing accommodation.
In my constituency—experience is perhaps helpful in debates such as this — there is good co-operation between the social services district offices of Cheshire county council, covering the Macclesfield area, and those who run private residential and nursing homes. I readily admit to Opposition Members that there has been a considerable growth in the number of both private residential homes and private nursing homes in my constituency. I balance that by saying that the majority of the proprietors worked previously in the public sector, establishing a fine reputation for the quality of the care that they gave the people in their charge in part III or similar institutions and homes. They are now transferring that care and expertise to the private sector and providing much money to open homes of the highest standard. The public and private sectors can work together to provide the widest range of good quality residential and nursing home accommodation for the elderly.
I think that the Government are open to some criticism. It is clear that they were taken slightly by surprise by the growth in the number of homes and the amount of money that is being spent through supplementary benefit on meeting the costs of those who are in private residential homes and private nursing homes. We should not seek to reduce the number of private residential homes or private nursing homes. Indeed, I should like to see their numbers further expanded so that they can be complementary to the continuing growth of part Ill and other specialist accommodation in the public sector. They should work together to a common end and objective.
§ Mr. Frank Field
Unfortunately, I did not hear the beginning of the hon. Gentleman's speech. He will understand why we are all so busy today. He has said that he wants an expansion of the private sector. Presumably he wants that for those who need the service that that will provide and not for those who are put into homes by their families.
§ Mr. Winterton
I greatly respect the hon. Gentleman's expertise in these matters. He and I often find ourselves on the same side of the argument. I said earlier that I agreed with the sensible argument of the hon. Member for Oldham, West — it was hidden within the political polemics, dogma and prejudice — that eligibility for supplementary benefit for a person to go to a home should be based to a greater extent upon need and not merely on the resources that might be available. That is important, and my hon. Friend the Minister has said that he will be dealing in some detail with this issue.
I regularly visit private nursing homes and residential homes in my constituency, such as Pott Hall nursing home near Bollington and Bryher house residential home, as well 340 as part III homes. I believe that the standards of care, facilities and expertise are extremely high. However, if there are to be private homes as a result of people putting up private capital, they should be properly inspected and carefully licensed before they are allowed to take the elderly, those who require specialist care, the mentally ill, the disabled and the severely handicapped, or whatever other category, and care for them, and they should be regularly and closely monitored.
As the hon. Member for Birkenhead (Mr. Field) knows, because of his expertise, it is easy to open a home with high standards, but unless the home is run properly and is carefully administered and there is proper supervision by those who know what they are doing, standards can quickly deteriorate. Those who go to a private home can be pleased initially with what they are given, but they may find quickly thereafter that they are not getting value for money. The care that they receive may be worse than that which was available to them in their own homes, where they were lonely, before their application for a place in a residential home or nursing home was accepted.
Unfortunately, the hon. Member for Wolverhampton, North-East (Mrs. Short) is not in her place. The hon. Lady chairs the Select Committee on Social Services with great decorum and distinction. If my memory serves me correctly, she has chaired the Committee and its predecessor Committees for about 16 years. I have been pleased to serve under her—I had better rephrase that. I have been privileged to serve with the hon. Lady on the Committee for about 12 years. We have established the sort of rapport, co-operation and understanding that was referred to by my hon. Friend the Member for Halifax (Mr. Galley).
The Select Committee on Social Services is perhaps the least glamorous of all the Select Committees, but I am not being immodest when I say that it is one of the most important, if not the most important, of all the Select Committees. Those who serve on it work exceedingly hard. They are backed by excellent staff and by equally excellent advisers who assist from time to time with our more important inquiries.
The Committee was told that £280 million was spent in 1985 on private and voluntary residential care for the elderly, and I have no doubt that my hon. Friend the Minister will tell us that the sum will be greater this year. It will probably be well in excess of £300 million. In the main, that is money well spent. With the rapid growth of expenditure in this area, however, the Government must monitor spending much more closely and have a more sensible and rational policy on the allocation of resources. At the same time, there must be the sort of flexibility that was referred to by the hon. Member for Caernarfon. On whichever side of the Chamber we may sit, we must surely have one common objective—to provide the very best accommodation and the most expert and caring care for the elderly who need to resort to residential or nursing home accommodation. Surely that must be a shared objective.
Much mention has been made of community care, a subject about which I feel fervently. On Saturday, I shall preside at the opening of a large garden fete at Parkside hospital in my constituency, which cares for the mentally ill. Over many years it has established the highest reputation for the care which it gives to those suffering from mental illness. Some of those people have been there for practically the whole of their lives, which means several 341 decades. The hospital, in the form which we know it, is threatened with closure. The health authority has suggested that it will replace it with two hostels for the mentally ill.
Community care is vital, and let us try to keep those who are handicapped, such as the mentally ill or the mentally handicapped, in their homes if we can do that by providing the right accommodation and properly qualified and appropriately skilled staff, but let us not put people out into the community merely to close a mental hospital or psychiatric hospital so that the hospital can be sold and we can realise capital assets by making the site available for building. We may put people into hostels, and some may be suitable for them, but what about the specialist facilities that are provided within hospitals? I have in mind sheltered workshops, hydrotherapy pools and other specialist facilities and accommodation. These things cannot be provided within a hostel complex. I hope that all hospital authorities will consider carefully what they are doing before fine hospitals are closed and lost for ever. There will always be a limited number of places required in long-stay hospitals for those who suffer from the more acute forms of schizophrenia, and we have all seen on television horrific documentary programmes about schizophrenics. This topic is close to my heart and I shall be making a plea publicly on Saturday at Parkside hospital that the authorities in my area—
§ Mr. Winterton
I am not worried about those who are not in the Chamber. I shall make the plea that the authorities will consider the long-term needs of those who require refuge and 24-hours-a-day hospital care.
The Select Committee has presented a good report and it merits a considered response from my hon. Friend the Minister. I am confident that we shall get it. I think that we are united in our objective for the elderly, and I hope that the Government will give us some reassurances this evening.
§ Mr. Allen McKay (Barnsley, West and Penistone)
It is a pleasure to speak after the hon. Member for Macclesfield (Mr. Winterton), and that shows how deeply hon. Members on both sides of the House care about the disabled, the weak, the infirm and those who cannot look after themselves. I congratulate my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) on the report and on the work that she has undertaken for so long on behalf of such people.
This issue is both important and highly volatile. The problem will not go away, but will rather increase. Without any shadow of doubt, people will continue to live longer as more facilities and medical services are provided, and that is, of course, only right. At one time, every family strove to look after its young and elderly. Now, however, families are often split up, either because a husband has had to travel the length and breadth of the country to find work or because he has had to follow up work that he has already undertaken. Thus, we must consider not only the problems outlined by the hon. Member for Macclesfield, but also the future.
When I was chairman of housing, I looked at this problem together with architects and planners. We found 342 that often those who might want to care for their parents were unable to do so, because they lacked the facilities. Consequently, I believe that we must plan and must think of creating space for granny flats. Some countries plan for the time when the children will have to care for their parents. Accordingly, they design their houses so that accommodation can be added on at a later date, enabling the parents to live their lives while allowing the children to do so, too. Of course, it also means that the parents are cared for.
The Yorkshire Post highlighted some of the problems to be found in certain private accommodation. It would be wrong to take a broad-brush approach and to condemn private accommodation as a whole. But, according to the report, there are areas of concern which I believe the House should consider. I also believe that we should reinforce the inspection arrangements undertaken by local authorities, or by local authorities acting in conjunction with the health authorities in some areas. According to the report in the Yorkshire Post, there must be constant vigilance to ensure that things are right. If we are to adapt to the increase in the number of elderly people, we must give them confidence in how private or part III accommodation is built and run.
I have no doubts about my local authority. Regular inspections are carried out not only by officers but by councillors. Councillors are encouraged to make regular visits to their part III accommodation. I visit part III accommodation, and only last Saturday I went to one of the homes. I got great pleasure from that home's oldest resident who had been there for more than 12 years. That resident congratulated those who care for the residents on their standards of cleanliness, on the food that was provided and on the care that had been shown. Indeed, in general, even better standards probably result from such expressions of thanks.
I greatly admire those who look after the elderly. They are very special people. However, sometimes general hospitals inadvertently act as homes. Those, in particular, who have no relatives will not be turned out of a general hospital even if they are taking up a valuable bed simply because the next stage, the geriatric hospital, is full and there is no part III accommodation.
Hon. Members must consider carefully the policy of care in the community. If we can build the facilities needed for care in the community, people will be far better off in the community than in part III accommodation, or in any home, however good it is.
Will the Minister give an assurance that he will consider those points? Will he also give an assurance that the report in the Yorkshire Post will not be put on one side but will be investigated? I hope either that things will be put right, or that the investigation will show that there was no substance to the report. But some investigation is necessary for the confidence and well-being of those in the area.
§ 6.5 pm
§ Mrs. Edwina Currie (Derbyshire, South)
I am no longer a member of the Select Committee, and this year I did not have the privilege of being involved in the report on the expenditure Estimates. But it is clear that, yet again, the Committee has done good work and I am glad that we are debating this subject today.
Statements about the growth in the expenditure involved and in the number of those receiving this form of 343 supplementary benefit have been well rehearsed. Paragraph 70 of the report states that the cost of payments to elderly people increased from £6 million in 1978 to an estimated £280 million last year. The number of recipients also increased from 7,000 in 1978 to 42,000 in 1984, and the average payment increased from £15.70 to £88 per week in 1984. One cannot go any further than that, because no one knows how many people receive that benefit or what its current cost is. But my guess is that the figure for the number of recipients may well have doubled during the past two years to 80,000, and that the suggested figure of £300 million is probably a very conservative estimate. If it has not yet reached £500 million, I should he most surprised.
When my husband and I were house-hunting in my constituency during the summer and autumn of 1983, we looked at several large houses. Nearly all of them have now been taken over and have received planning permission for use as private old people's homes. Indeed, I now have the considerable pleasure of visiting them and opening them at the rate of approximately one a month. I am delighted to note the standard of care that they offer. Those involved have certainly made a much better job of renovating the properties than I and my family would have done. I have no doubt that they are doing a first-class job, and I am glad to put that on the record.
I had intended to comment on the speech made by the hon. Member for Oldham, West (Mr. Meacher), but I am bereft; my quarry has flown. He has scuttled off to have his tea. Perhaps that is the greatest compliment that he could pay me, but—
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. John Major)
The hon. Member for Oldham, West (Mr. Meacher) has, to my certain knowledge, an engagement outside the Chamber. Before he left, he told me that he greatly regretted that it was unavoidable. I know that he would particularly regret being unable to hear what my hon. Friend wanted to say to him.
§ Mrs. Currie
I am even more astonished that my own Minister should apologise on the hon. Gentleman's behalf, but there we are. It shows what an honourable and decent gentleman my hon. Friend the Minister is.
I listened to the comments and criticisms of the hon. Member for Oldham, West, and waited in vain for a word of congratulation on the tremendous growth in expenditure, which has done so much to help many more people and which helps to care for such a large proportion of our elderly people. I could not figure out whether the hon. Gentleman was in favour of that growth in expenditure and wanted it to be increased, or whether he was agin it, and would like to cut it out entirely. That is why I asked him about his attitude to private residential care. I was interested in what he said. He said that he understood that private homes could not all be closed, but that he believed that the private residential care sector should not expand. That is what he said, and I understood him to mean that the Labour party might have a policy of freezing all places and of keeping the number at its present level. I also understood him to mean that no more such homes should open and that there might be a ban on giving planning permission to any such future homes.
Perhaps one of the Labour Members present can tell me whether the hon. Member for Oldham, West had authority 344 to say all that, or whether he was thinking on his feet. If he did not have any authority to say that, does he intend to return at some future stage to say that private residential care should be expanded—something which I would welcome—or that such homes should be closed? I suspect that the latter is what he would like, if he had half a chance.
It is also worth pointing out that the Select Committee confirmed something that Government Members have believed for some time: that it is the DHSS rate of benefit which sets the level of prices and rents charged. In paragraph 72 of its report the Select Committee discussed the history of this benefit. The paragraph says:landlords raised their prices to meet the limits.Hon. Members will remember the many occasions when Government Members have said that that was exactly what was happening, that if levels of benefit are increased the rents and charges will go up. Opposition Members said no, that could not happen and that the charges accurately reflected the absolute necessity to pay amounts of that sort. Of course it happens, and the DHSS is at last aware of it. I am glad that the Select Committee has confirmed it in such a competent and efficient way.
I am worried about the increased dependence of the private system on state funding. I should like to quote some figures from the parliamentary panel on personal social services, covering the period from 1979 to 1984. It says:while private provision has nearly doubled, supplementary benefit payments have increased 20-fold.As a result, the percentage of the independent sector financed through supplementary benefit has increased from about 14 per cent. in 1978 to 40 per cent. in 1984. My guess is that that figure must now be over half and may be as much as two thirds of the private sector. Certainly most of the growth in the last couple of years must have been financed substantially by the state supplementary benefit system.
I am never happy when I see a private profit-making industry, however competent, drawing most of its revenue from the state, especially when that percentage is rising so sharply. The Government now face a substantial and well organised pressure group which did not exist before. It has been sending papers to the hon. Member for Oldham, West which he busily read out. That will make it difficult to do what the hon. Member for Oldham, West wants to do, which is to stop any further growth.
My hon. Friends will know that I support almost any effort to reduce the burden of social security. I read for the first time in connection with this debate the booklet entitled "Supply Estimates 1986–87". There are some nuggets in there about how we might do something to reduce expenditure while improving the quality of care. We are talking about residential care, and I should like to mention one item of expenditure. It is only £3.5 million but it is quite interesting and is contained in page 24 at section G2.
The section says that we provide maintenance and treatment for about 59 severely disturbed children and young persons at two national residential centres. It costs us £3,672,000 a year. That works out at £62,000 per child per year, or more than £1,000 per week. I know those two centres. They are St. Charles in Essex and Glenthorne in Birmingham. If the DHSS would like to improve the quality of care that it is giving to young people and save some money on residential care, that is obviously 345 something that it could have a go at. Local authorities pay about £1.5 million back into the kitty and that simply means that the cost to the Exchequer is reduced to about £30,000 per child per year. On that basis, we could buy Eton, let alone buy places at Eton for the children concerned, and they might be whacked into some kind of shape. That is one example that I commend to my hon. Friends.
My hon. Friends also know about the problem posed for these Estimates by the fact that the increasing numbers of elderly people will get worse. I listened to the speech of my hon. Friend the Member for Eastleigh (Sir D. Price) and I found it very moving and accurate. He said that the demand for residential care was bound to grow. The Minister of State said the same thing to the Select Committee and was quoted by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood).
The numbers are quite frightening in many ways. In 1961 we had fewer than 2 million people aged between 75 and 84 and barely 250,000 over the age of 85. By 1996, in 10 years' time, we will have 3 million people aged between 75 and 84 and I million aged over 85. Together they will form 7 per cent. of the population. We all know that that is happening because those people are here now. Some of them are sitting in the Chamber and I hope that they will achieve this great age. A number of them form a substantial majority in the other place and give excellent service to the nation. I hope to join those numbers of elderly when the time comes.
§ Mr. Frank Field
Is not the hon. Lady being slightly unfair to the other place? Surely that is a model for the type of local authority home that we ought to have in every district. It has a speaking room, a sleeping room and an eating room. There are no nurses in white coats, only people in black suits and the residents are called my Lord and my Lady and they live for ever. That is not something to be abolished but something to be spread throughout the nation.
§ Mrs. Currie
That is a well-put point. They are also a great deal more with it and modern than we are in this House, having insisted that their proceedings should be televised—and a very good job they do of it.
We all know about these figures and quote them. They are in all the reports, but is anybody planning to listen on the basis of what these figures really mean? Is the Treasury listening? Are the figures being built in? According to the Select Committee report, the DHSS managed to get it wrong to the tune of over £1 billion this year. That makes one wonder whether the DHSS is listening. I am aware that the statistics, according to the Select Committee, on which a great deal of DHSS planning is done are a little inadequate. I understand from paragraph 67 that the latest available data relate to 1981 and that the DHSS has problems with the 1983 family expenditure survey, but it is worth reflecting what those increases in numbers mean. This budget and this group of Estimates which are causing such headaches in the DHSS could have been foreseen and will continue to grow.
It is the same in other parts of the public services. The elderly use nine to 10 times as much of the National Health Service as fit younger people. Is that factor being built in? If it is not, that helps us to understand why the tremendous real increase in expenditure on the National Health Service 346 —the figures that the Prime Minister quoted on the radio this morning — seems to vanish into thin air. It is because the people using the Health Service are not the same people as they used to be and their requirements are now quite different.
My hon. Friends on the Front Bench know that I have been one of those calling for an assessment system for the people gaining admission to the private homes and who are able to claim supplementary benefit. If we are to achieve our dual objectives in this field — to cope with the increasing numbers of old people with some dignity and give them the right and opportunity to live in some comfort and at the same time to keep the budget under control — the budget cannot be demand-led and unrestricted for much longer. We are not being unkind when we say this because this rapid growth deprives other elderly and disabled people who may well be in much greater need. I deeply resented the remarks of the hon. Member for Oldham, West, who said that such things as home helps and meals on wheels are not Government priorities. They are Government priorities and we have seen rapid expansion in both services under Conservative Governments and Conservative councils.
The key is to ensure that the people receiving the funds that we are debating are in both financial and physical need. Some assessment system has to be devised which does more than look at their financial requirements. The DHSS will have to develop a system under which it can say no and can say to the fit and active 60-year-old, "No, you do not need to live in an old people's home and if you do we will not pay for it until such time as you need it."
§ Mr. Allen McKay
Would the hon. Lady turn the argument round and say that we should also provide sufficient money to local authorities to enable them to build more aged people's homes so that people would have to come out of their three and four-bedroom houses and would not need to go into part III accommodation?
§ Mrs. Currie
The hon. Gentleman has misunderstood me a little, and if it is my fault, I apologise. I do not particularly want to see a growth in council-run homes. I do not mind who runs the homes, as long as they are well run, and I do not mind who pays for the homes, as long as when it is the state—which it is increasingly and, I suspect, to the tune of rather more than half the amount that is going into the private sector—we should have some say as to whom the money goes to and as long as there is some recognition of need. I should be perfectly happy if all the homes were run by the private sector. If they could be run to the same standards of quality as those in South Derbyshire, that would be absolutely marvellous.
§ Mr. McKay
Perhaps I may put the hon. Lady right. I was not referring to who provides the accommodation; I was referring to bungalows for the aged. They would enable those who are now living in three-and fourbedroomed houses to move into smaller dwellings and still live in the community and care for themselves, which they cannot do while they are living in three-or four-bedroomed houses.
§ Mrs. Currie
I agree entirely. If the hon. Gentleman ever has time to look at my record as housing chairman in Birmingham, he will find that that is exactly what I did.
347 I call attention to one sentence in paragraph 75 of the Select Committee's report. The Committee did not highlight this sentence, but it sums up everything that has been said in this debate. It says:A clear national policy for the support of the elderly inside and outside residential care must be devised.That is absolutely right. I have complete faith that the Government and the Ministers who are on the Treasury Bench today will devise such a policy, and I call upon them to do it as soon as possible.
§ Mr. Frank Field (Birkenhead)
Many hon. Members will know that Martin Gilbert created a cottage industry by producing many volumes on different aspects of the life of Winston Churchill. One of those volumes records the fact that when visitors who had been invited to Chartwell approached the summer-house in the garden to greet Churchill they heard the grand old man say, "Mr. Speaker, I did not expect to be called today." I did not expect to be called today. However, I want to put four points to the Minister, although I did not rehearse them in my summerhouse at Chartwell before I came to the House.
First, will the Minister respond to the pleas from both sides of the House that access to old people's homes should be controlled? I am not asking that question, as the hon. Member for Derbyshire, South (Mrs. Currie) emphasised, only because of concern about rising costs and the contribution made by the taxpayer. I am asking it because I believe that old people's homes are meant for those who are unable to survive in the community and that access should he limited to them. Both sides of the House have suggested that local authorities would be in a good position to determine who should have access to them.
The Minister probably expects Opposition Members, if not Conservative Members, to say that local authorities would find it difficult to undertake that task if they were not provided with additional staff. Considerable savings can be made if money is moved from one Department to another. In this case, money would be moved from the Department of Health and Social Security to the local authorities. Given that there is all-party agreement, I hope that the Minister will have something positive to say about that when he replies to the debate.
Secondly, in his typically powerful way, the hon. Member for Macclesfield (Mr. Winterton) referred to the need to check the standards of this form of service. He drew a distinction between the need to ensure that somebody can provide a service and what can happen to that service over a period if we as a community do not keep a friendly eye on it.
I am not making a plea for a form of police force. Although all hon. Members can point with considerable pride to the local authority and private sector services in their areas, I guess that many of us are worried about the services that are provided by some of those who have newly entered the field. This is partly because some people want to make a quick buck, but in other cases people are unaware of the correct standards and how they can be maintained over a period.
§ Sir David Price
Does the hon. Gentleman agree with my suggestion that the DHSS should develop an inspectorate along the lines of Her Majesty's inspectorate of schools, which has a positive role to play?
§ Mr. Field
I did not expect to be called today, but I made a note to refer to that point if I was called. I have 348 not heard that suggestion before. My thinking has been typically local authority dominated, but the suggestion is valuable. Although the hon. Gentleman did not refer to it in his speech, I am sure that we have all grasped the paint that if an inspectorate can cross local authority boundaries it will pick up the best practice and the worst practice in different local authorities, whereas a single local authority has only its own area from which to build up its expertise.
I hope that the Minister will refer to the need to maintain the standard of care that is provided for frail and sometimes confused old people. Clearly they are vulnerable because of their confusion and frailty. Furthermore, as the hon. Member for Derbyshire, South said, a large amount of public money is now being directed to this area. Therefore, we ought to ensure that the money is spent in a way that would make us happy if we were residents in any of these homes, of if members of our family were resident in them.
Thirdly, I hope that the Minister will answer the point made by the hon. Member for Eastleigh (Sir D Price) about the attendance allowance. He criticised the fact that the rules governing the use of the attendance allowance to help to pay for the total cost of a stay in a home have been changed. I disagree with him about that. I thought that it was a sensible change. It did not lead to taxation of the benefit. It provided that if the charge made by the home was higher than that which would be covered by supplementary benefit, the attendance allowance should be taken into account. That is reasonable. What is completely unreasonable is that when that change was made many of our constituents had their attendance allowance, or part of it, taken into account for the first time in meeting the cost of their place in an old people's home. The rest of the allowance was frozen or, more accurately, was lost. When the next round of increases in charges took place, that part of the amount that had been frozen was not unfrozen. This is a particularly important point to which I hope the Minister will respond.
In Birkenhead, the lawyer who works with me and who has caused the Government so much good trouble, Nick Warren, took the case of one of my constituents to a tribunal. The tribunal ruled that the Government were behaving unlawfully. The first messages from the Department were slightly cocky. The Department said that it would challenge that ruling. However, it has not done so, for the simple reason that it now thinks that it would lose. As the Department does not believe that it could get the decision overturned, does it not have a duty to consider whether all those in old people's homes who have claimed attendance allowance but who have had most of it frozen, and who have therefore lost it, ought to be treated more equitably and fairly, as my Birkenhead constituent is being treated because the Department lost its case before an independent tribunal?
My last point is perhaps the most fundmental. We cannot expect the Minister to undo what has happened since 1980, but many of us must be unhappy that we have seen an increase in expenditure from the DHSS when, under other circumstances, one would have expected to see that expenditure from the local authority, even if that local authority was spending money in private provision as well as providing within the local authority sector. It undermines the Government's position when they regularly tell us that they cannot expect the DHSS to pay students money because that is an education function, yet they are paying large sums of money —it may be £500 349 million, as the hon. Member for Derbyshire, South said —under the guise of supplementary benefit. That is a payment of allowances to people in the community, but we are talking about people who cannot live in the community and are covered by the provisions of an old people's home, whether private of public.
I end where many other hon. Members began, by thanking the Select Committee for producing this report. Like so many other of its reports, it is valuable. The subject that we have been discussing touches on a growing number of our constituents who, because of their frailty and age, are least able to look after and protect their interests. For that reason, if for no other, we are grateful to the Select Committee.
§ The Parliamentary Under-Secretary of State for the Home Department (Mr. John Major)
This is an important and wide-ranging subject, and the quality of the debate this afternoon has reflected that very well.
I take my grace note from the hon. Member for Birkenhead (Mr. Field) and others by congratulating the hon. Member for Wolverhampton, North-East (Mrs. Short) on introducing the Select Committee report, and on the manner and style in which she did so. I thank her also for her courtesy in making available earlier this week an advance extract on "Private and Voluntary Residential Care for the Elderly" from the Select Committee on Social Services report, which was published this morning. That was most helpful as it was the staple core of the debate, and I am extremely grateful.
A number of highly relevant matters have been raised this afternoon, as they were in the Select Committee report, and I shall endeavour to respond to as many as possible. It is entirely appropriate that our discussions should be based on an estimate of expenditure because, as both the Select Committee and almost every hon. Member who has spoken have commented, there has been a dramatic increase in cost for supplementary payments for residential and nursing homes and care in recent years. There is a variety of reasons for this, some of which were touched on. They are the increasing numbers of elderly people, the rising age profile, greater knowledge of entitlement to supplementary benefit, which has played an important part, and the availability in recent years of the supplementary benefit payments.
There is no doubt that expenditure on provision of accommodation and care for the elderly has inevitably risen over recent years. The availability of the supplementary benefit entitlement has provided an option for the elderly which previously would have been open only to a minority with substantial private resources. Many hon. Members will welcome that extension of options. Without that option, however, the choices for the elderly would have been more limited than they are. They would have had to rely simply on the help of their own resources, if they had any, or on the support and resources of their family, if their family had any, or on the capacity of the local authority to use its permissive powers to assist. The provision of supplementary benefit limits, whatever the individual criticisms may be, has extended an option that has brought for many elderly people a level of care and individual satisfaction that otherwise they may not have received.
350 The present position has evolved as a result of a number of policy changes, largely familiar to the House and accurately detailed in the Select Committee's report and set out by the hon. Member for Wolverhampton, North-East. In view of the points that have been raised, I shall not reiterate the historical perspective of the situation in which we find ourselves.
It is true that in the period up to 1984 there was a huge increase in the number of people being helped with residential care and nursing home fees through supplementary benefit. The statistics, although already noted, are worth repeating, for they are startling. In 1978, supplementary benefit helped 7,000 people with their fees. The related expenditure was £6 million. In 1984, there were 42,000 claimants, and expenditure had risen to £190 million. Expenditure had in effect gone up thirty-fold in six years.
The hon. Member for Wolverhampton, North-East specifically touched on this growth, as did my hon. Friends the Members for Eastleigh (Sir D. Price), for Macclesfield (Mr. Winterton) and for Derbyshire, South (Mrs. Currie). They referred in detail to the certain demographic growth in the number of claimants. We have had to bear that in mind in determining the structure of assistance that we have provided. We have always to bear in mind the twin needs of providing the maximum amount of assistance that we can afford and ensuring that the relevant resources are used in the most satisfactory fashion; the Select Committee pointed out the desirability of doing that.
The new structure that we introduced in 1985, although not specifically the subject of the debate, is intended to target help better and prevent abuse. The old local limits have been replaced by a new national structure of limits related to the specific category of care provided. We did not just dream up those categories. They were drawn from the Registered Homes Act and the limits were determined from information about the differential costs of providing the appropriate levels of care for different client groups.
I am grateful to the hon. Member for Oldham, West (Mr. Meacher) for acknowledging, as did the Select Committee, the recent changes in the supplementary limits. Those changes were specifically designed to give extra help where it is most needed, and added flexibility to the new structure within which we operate. To put them in their context, the changes follow an interim uplift of £10 given last November for all types of residential homes, and a substantial increase of £37.40 for nursing homes. The main new changes in addition are a further increase of £5 in the new limit for residential care homes for the elderly, a new limit of £140 for elderly people who are blind or who qualify for the higher rate of attendance allowance, and a special extension of £17.50 for people living in residential care or nursing homes in Greater London. A number of points have been raised by hon. Members this afternoon, and I shall endeavour to deal with them as and when I deal with hon. Member's specific observations.
The hon. Member for Wolverhampton, North-East spoke with all the authority of the Chairman of the Select Committee. She spoke specifically of the extent to which she believed that supplementary expenditure on residential and nursing home care may have been out of control. I emphasise that they were her words rather than mine. The normal supplementary forecasts are based on a disaggregation of different client groups, and not on different household categories. Because of the specific 351 concern about board and lodging payments in 1984, special estimates were made in the Department about future expenditure in this sector.
As the supplementary benefit annual statistical inquiry showed, between December 1982 and December 1983, expenditure for people in residential care and nursing homes rose from £39 million to £105 million. Using those figures as a base, it was estimated that by December 1984 expenditure would increase to £190 million and would continue to increase by about 50 per cent. a year. Those estimates took account of foreseeable changes — for example, in the number of elderly people — but some other factors had to be considered which cannot be precisely quantified, such as the demand and need for residential care and the level of charges for it.
The expenditure figures from the annual statistical inquiry have not been fully analysed. In terms of the number of claimants, our estimates look remarkably accurate. We estimated that the number of claimants would increase from 25,800 in December 1983 to 42,500 by December 1984. The number for December 1984 was 42,000, so our estimates were perhaps rather more accurate than one may have been led to believe by the growth in global expenditure in that point. Perhaps the Department had the expenditure under tighter control than many may have supposed.
The hon. Lady also referred specifically to the desirability of comparable standards in public and private sector homes, and I agree with her about that. In 1984 we made it clear that local authorities should be consistent about standards across the sectors, and we have repeated our blandishments in 1986. The social services inspectorate inspects both public and private homes. It has a specific power to do so as and when it thinks it appropriate on a selective basis, but the prime responsibility for inspecting voluntary and private homes remains with the local authorities under legislation. So far as we can see, that is desirable and we expect that that will continue to be the case. We have a two-year monitoring study in hand and a report due towards the end of the year which may give us more information than we have had on an important and relevant part of this area.
The hon. Lady asked whether homes were being squeezed out of business. I understood her to say that, when the Department was asked, it appeared not to know the answer. I cannot respond precisely to the questions asked at that time and I do not have before me the answers that may have been issued, but there is no evidence now of homes closing because of the new structure. On the contrary, it remains a sustainable business, as the Select Committee stated in its report published this morning.
The Ernst and Whinney study on homes' costs also showed that homes could be profitable when charges were set at the supplementary benefit limits. I must emphasise that most residents are privately financed. Supplementary benefit supports about one third of those in independent homes, and more than two thirds are supported by their own resources or other than through the supplementary benefit system.
§ Mr. Wigley
Will the Minister confirm that the Ernst and Whinney assessment of the cost of homes was based on shared rooms, and that the Government's policy is for single rooms? Where does that put the assessment of the figures?
§ Mr. Major
I would not confirm that the assessment was based on the cost of shared rooms. The study took account of a variety of different factors. In reviewing the limits we considered a wide range of information on the gross unit costs per place and on charges for single and shared rooms, representations from interested people and organisations, and a variety of other factors. Therefore, the assessment was not based simply on shared rooms. I hope that the hon. Gentleman will find that explanation of some comfort.
I shall return to a matter which has run through the debate, but first I shall touch on a related matter which was perhaps not specifically raised today but which was certainly raised in the Select Committee's report, and that is the recommendation that we should consider urgently the relationship of board and lodging payments to the new income support scheme. We accept the Committee's observations in that regard. We shall consider the future structure of payments for ordinary board and lodging during the coming months and issue proposals for consultation as soon as possible.
My hon. Friend the Member for Eastleigh touched on a number of confusions arising from the various sources of assistance for elderly people through residential care in the private sector, care in the voluntary sector and local authorities. It is perfectly true that the present relationship between the main supplementary benefit scheme and other forms of support for people in need of residential care is confusing and unsatisfactory. That has been the view of many hon. Members who have spoken this afternoon.
Obviously, support for those who cannot afford to pay for themselves can be provided either through supplementary benefit or from local authorities. However, it is clear that the parallel systems of local authority and supplementary benefit support overlap, and that the differences between them are confusing for people who run the systems, the staff who work within them, and, most important, for the people who require to be assisted by them. There are, for example, different rules about the assessment of clients' resources for both systems.
Because we recognise the anxieties raised by the hon. Member for Oldham, West and others, we have a major programme of work in hand to review the arrangements for the financial support of residents in local authority, private and voluntary residential care homes, and to improve collaboration between the Department and local authorities in this area. We are setting up pilot studies which will test the feasibility of using local authorities' existing assessment arrangements to assess the need of supplementary benefit payments for residential care. That point was raised specifically by the hon. Members for Birkenhead, for Caernarfon (Mr. Wigley) and for Oldham, West, and my hon. Friends the Members for Macclesfield and for Eastleigh. The report is in hand.
We are also seeking to examine the position of local authorities advising DHSS—[Interruption.] I am not sure whether the hon. Member for Knowsley, North (Mr. Kilroy-Silk) has been present throughout the afternoon. He is always a welcome refugee from his sun lamp, but so far as I am aware, although he may have been actively engaged this afternoon, he was not actively engaged in the Chamber. If he will allow me, perhaps I can turn my mind to responding to hon. Members who have been actively engaged in a good purpose this afternoon.
The pilot study will investigate the possibility of local authorities advising DHSS local offices on appropriate 353 levels of payments for particular homes. I acknowledge the reservations on assessment and the pertinent points made by my hon. Friend the Member for Halifax (Mr. Galley). We have also set up with the local authorities a second joint working party to consider ways of harmonising financial support for people in residential care homes. The relationship between financial support for residential care and the income support scheme will depend on the outcome of the joint working party which we expect will report by Easter next year. The working party is considering three main options, at least one of which was trespassed on by the hon. Member for Birkenhead in his intervention in the speech of my hon. Friend the Member for Eastleigh.
The first option is that all support for residential care will be funded through benefits; the second is the opposite approach, with all support being provided by authorities; and the third, which may appeal most to my hon. Friend the Member for Macclesfield, is a mixture of the two with the support for the board and lodging element to be funded through benefit and with the care costs being met by local authorities. That matter was raised by many hon. Members, including the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), and we shall have to await the results of the discussions and consultations on it.
At the moment all options are open, but, as the House will appreciate, any of the proposals would involve major structural changes and I do not underestimate the difficulty of carrying those through. However, we are anxious to find the best possible mechanisms for assisting the elderly to obtain suitable accommodation while retaining, as the Select Committee is clearly anxious that we should, a proper control over public funds. I can assure the House that once we have firm proposals we shall make them available to the House.
§ Mr. Major
I said a moment ago that we hoped to have the report by Easter next year, and I hope that the hon. Gentleman will accept that. As to legislative matters thereafter, that is not a matter for which I am responsible at this moment, despite the eager anticipation that raced into the hon. Gentleman's eye as he leaped to his feet.
The hon. Member for Oldham, West, alas, missed the benefit of the speech of my hon. Friend the Member for Derbyshire, South which referred to many of the remarks that he made and in so doing substantially truncated the remarks that I would have made, for which the House may be truly grateful. The hon. Gentleman suggested that the national limits that we introduced in April last year might have been too low. The limits were set on the basis of the best information that we had available to us. They were intended to enable reasonable charges to be met and they were successful in that endeavour.
When we introduced those limits we promised a full programme of monitoring and research. As a result of the initial feedback from that programme, we made substantial increases to the limits last November which, as the hon. Gentleman will know, now range from £120 to £180 for residential care homes and from £170 to £230 for nursing homes. Hon. Members will know that we have just completed a full review of all the board and lodging limits, the results of which I referred to a few moments ago.
354 I am unable to accept the hon. Gentleman's underlying point. Broadly speaking, the limits were at a relatively adequate level and subsequent research has shown that to be the case.
§ Mr. Meacher
I said, not that the limits were too low, but that they failed because there is a single national limit, albeit with a variation for central London. They fail to take into account a wide variation in gross unit costs. Does the Minister have any intention to try to make the limits reflect economic realities more closely? In the absence of that, the shoe will pinch in a number of places and I fear that there may be evictions of a number of persons whom I am sure that neither he nor the home owners wish to evict, but that is the economic reality.
§ Mr. Major
I understand the point on which the hon. Gentleman now enlarges. He will be aware of the special assistance, particularly for the London area, that was made in the announcements which will come into effect from 28 July. Indeed, my hon. Friend the Member for Eastleigh also referred to that specific point, so I shall respond to it now.
We looked generally to see whether there are substantial regional variations. It is true that there are modest variations within regions and that will almost invariably be the case. The only area that our monitoring shows really merits a substantial increase in the limit is the Greater London area, and we have made a substantial increase in the new limits that will come into effect from 28 July.
I understand — some of the residential care home owners touched on similar points when I met them—that there are within regions areas that are noticeably more expensive than others, but it is also fair to say that if we are to retain the financial control that we are invited to retain, quite rightly, by the Select Committee, we must set relatively broad limits to ensure that residential homes do not necessarily spring up in what may well be the most expensive and not necessarily the best areas for their functions to be carried out. Therefore, I hope that we shall not face the gruesome possibilities that the hon. Gentleman outlined.
The hon. Gentleman also raised the question of residential care homes not taking people on benefit. There have always been homes where it would not be reasonable to meet the charges at the expense of supplementary benefit and that remains the position. I emphasise that limits are not designed to meet exceptionally high charges. We could not obtain budgetary control if we did that. However, if someone has particularly serious health needs, health authorities and local authorities retain all their powers and duties to provide or to pay for care at the appropriate rate. We hope and expect and have evidence that in those special circumstances they will take up the responsibility that Parliament has invited them to accept.
The hon. Member for Caernarfon in, to echo the words of my hon. Friend the Member for Macclesfield, an excellent speech, asked for a view on the suggestion by the Spastics Society that people with multiple handicaps should be entitled to the amount of benefit available to people in nursing homes even though they may not be in nursing homes but are perhaps living in residential care homes. We recognise the particular problems of this specific group. My hon. Friend the Minister for Social Security has discussed the proposal with the Spastics 355 Society, but I am bound to say that supplementary benefit cannot meet all care costs however high and our local offices do not have the expertise to determine which groups need the higher levels of care. Local authorities have a role to play in the provision of care.
There are, as the hon. Gentleman will know, some topping up provisions which have given local authorities added flexibility to deal with certain people who fall in that particularly difficult area. We are hoping to have further discussions with the local authority associations and the voluntary sector on what improvements might be made to the particular difficulties faced by the group that the hon. Gentleman mentioned.
My hon. Friend the Member for Eastleigh spoke about regional variations and rightly had in mind the particular difficulties faced in Hampshire and in his constituency of Eastleigh. To add to the observations that I made a moment ago to the hon. Member for Oldham, West, our local office survey specifically showed that charges in the London south and London north social security regions were generally above the national average. But for most categories of home the difference was not significant. In all but one category in each region the difference was less than 10 per cent. and the clear pattern of significantly higher charges of London has not been repeated in the south generally. However, we shall keep a close watch on that, particularly in view of the remarks made by my hon. Friend the Member for Eastleigh.
My hon. Friend the Member for Halifax spoke rather against the light in terms of the prevailing sentiments in the debate and a speech is none the worse for having done that. He had some qualms about an assessment system and the possibility of introducing a bureaucratic straitjacket. He mentioned related problems that clearly would exist were we to move towards a specific assessment system. I hope and expect that those particular concerns will be discussed in the meetings that we have in the study group to determine how we may take the problem further.
My hon. Friend the Member for Macclesfield, in a typically robust speech, ranged widely across the spectrum. His core concern was on the desirability of assessment of need. I hope that he will accept that my remarks a few moments ago about the studies that we are carrying out in order to look at the problem will give him some reassurance that we fully take on board the worries that he has mentioned.
My hon. Friend also referred to the desirability of the expansion of private residential care to complement part III accommodation. I wholeheartedly endorse the way in which my hon. Friend put it. It is a substantial complementary factor to the part III accommodation which, as my hon. Friend says, now has to deal with people who often require more care than has traditionally been the case. The assistance that is provided by the residential and voluntary care sector will have been of significant assistance to those people who provide splendid care in part III accommodation.
The hon. Member for Barnsley, West and Penistone (Mr. McKay) spoke of the importance of the inspection of homes and related matters. He will know that local authorities have an obligation to inspect registered residential care homes at least once every 12 months, although they are encouraged to inspect them more often if they believe that to be necessary.
In addition, the health authorities have statutorily to inspect nursing homes twice every 12 months and the 356 authorities have the power to withdraw registrations if standards are not maintained. I emphasise that that power exists for them to use if they feel that it is necessary. I can also tell the hon. Member for Barnsley, West and Penistone— he may find it reassuring—that the social services inspectorate is carrying out a two-year study to see how the Registered Homes Act 1984 is being implemented, including standards in the homes. We expect its report on this important matter at the turn of the year.
The hon. Gentleman also spoke of recent reports in the Yorkshire Post. He will understand if I do not refer specifically to the content of those reports. However, it is for the authorities with responsibilities to register and inspect the homes to examine those reports. In the belief that the hon. Gentleman may not have yet done so, I shall draw his remarks to the attention of those authorities.
My hon. Friend the Member for Derbyshire, South spoke robustly as ever and with typical good sense. Her comments about parts of the speech of the hon. Member for Oldham, West robbed me of many of the golden remarks I would otherwise have made, for which the hon. Gentleman may be thankful and the House may be grateful. My hon. Friend spoke about the need for assessment for supplementary benefit claimants. I hope that she will find my earlier remarks of some reassurance.
The hon. Member for Caernarfon referred to the possibility of shared rooms. I believe that I dealt with that in an intervention during his speech. I hope that he will find those remarks acceptable.
The hon. Member for Birkenhead raised a series of matters, many of which I have already dealt with. He also raised the question of the treatment of attendance allowance under the transitional protection provisions. The chief adjudication officer issued revised guidance for adjudication officers some weeks ago. Operational guidance asking local officers to review cases during the uprating exercise has also been issued. Arrears of benefit will be paid where appropriate. The regulations have now been amended to put the law back to what was originally intended. However, claimants will get the benefit of an increase in their transitional protection through the uprating addition of up to £10 which we introduced at the same time.
§ Mr. Frank Field
May we take it, as a result of the chief adjudication officer's decision, that all of our constituents who are in old people's homes and who claim the attendance allowance and had part of it frozen under arrangements which I understood and support will have further parts of that unfrozen as the charges of the local authority home increase and rise above the supplementary benefit level?
§ Mr. Major
I believe that I know the answer to the hon. Gentleman's question, but it would be safer for me to write to him rather than mislead him or, more relevantly, mislead those outside the House who may read reports of the debate. I shall undertake to write to the hon. Gentleman within the next day or so on that point.
I believe that we have had a worthwhile and, I trust, helpful debate. My hon. Friend the Minister for Social Security and I will reflect carefully on the many views expressed, especially those upon which there has been a broad consensus among those who have spoken in the debate. We are not in any way complacent about the present system and we entirely recognise the need for greater flexibility.
357 As I said earlier, we have in hand already an urgent programme of work for the future and we look forward to carrying it through. What is certain and quite clear is our intention. We wish to ensure that residential care is on a firm footing so that the elderly can get the care they need. We wish to ensure that there will be alternatives to the excellent care so often provided by local authorities and that the resources used for that purpose provide the best value for the community that can be obtained. I believe that those are aspirations which command widespread support, and I commend them to the House.
Question deferred, pursuant to paragraph (4) of Standing Order No. 19 (Consideration of Estimates).